Journal of Orthopaedics 13 (2016) 431–436

Contents lists available at ScienceDirect

Journal of Orthopaedics
journal homepage: www.elsevier.com/locate/jor

Original Article

Chronic hip dislocations: a rarity. How should we treat them?

V. Selimi a,*, O. Heang b, Y. Kim b, E. Woelber c, J. Gollogly b
a
University of Cambridge, Cambridge, England, United Kingdom
b
Children’s Surgical Centre, Phnom Penh, Cambodia
c
WWAMI (Washington, Alaska, Montana and Idaho), USA

A R T I C L E I N F O A B S T R A C T

Article history: Background: Chronically dislocated hips (>6 weeks) are usually the consequence of difficulties accessing
Received 25 January 2016 appropriate healthcare in a timely fashion after dislocation; this explains why they are more common in
Received in revised form 22 July 2016 developing countries. Due to a lack of research, there is currently no consensus on the best treatment
Accepted 2 September 2016
available for patients presenting with this condition. Therefore, it is important to assess the treatments
Available online 23 September 2016
available so as to ensure that doctors adequately manage those presenting with this debilitating
condition in the future.
Keywords:
Objective: To identify the best treatment strategy for chronic hip dislocations based on the treatment
Chronic
Hip dislocation
outcomes achieved by a free surgical clinic in Phnom Penh, Cambodia.
Patients and method: A retrospective analysis of the surgical centre’s electronic records was conducted.
Patients presenting with hips dislocated for >6 weeks were included whilst congenitally dislocated hips
were excluded. Treatment outcomes, based on follow up notes, were then assessed. Data abstracted
during chart review was analysed using descriptive and comparative statistics.
Results: 72 patients presented to the clinic with chronic hip dislocations. 42 patients received recorded
treatment and 32 were followed up. Among patients with follow-up, 63% experienced ‘good’ outcomes
after treatment. Open reductions, the most common treatment, were successful 65% of the time. The use
of preoperative traction increased the success of open reductions by 13%, however, this result was not
statistically significant (p = 0.64).
Conclusion: Open reductions with pre-operative traction seem to be an acceptable treatment in this
setting.
ß 2016 Published by Elsevier, a division of RELX India, Pvt. Ltd on behalf of Prof. PK Surendran Memorial
Education Foundation.

1. Introduction Chronically dislocated hips (>6 weeks) are a rarity in many

Dislocated hips are treated as emergencies in developed
countries. When reduction of the hip is delayed, the femoral head
migrates proximally, causing a leg length discrepancy while
compromising vascular supply from the foveolar artery and the
anastomosis of vessels from the femoral circumflex arteries.
Possible complications stemming from the delay of treatment
include avascular necrosis of the femoral head, degenerative
arthritis, ankylosis, and sciatic nerve injury.1–4 It has been shown
that earlier reductions are associated with better clinical results.5,6
regions of the world where there is rapid access to healthcare; this
has resulted in scarcity of recent scholarship assessing the
treatments available for this condition. As chronically dislocated
hips are more common in Cambodia, the aim of this study was to
assess which treatment approaches provided at a free NGO clinic in
Phnom Penh, Cambodia, have yielded the best outcomes for
patients, in order to help guide the future practice of doctors who
do encounter this problem.
2. Materials and methods

2.1. Case identification (data abstraction)

* Corresponding author at: Children’s Surgical Centre, Kien Khleang National
Rehabilitation Center, Khan Ruseykeo, Sangkat Chroy Changvar, Phnom Penh,
Cambodia.
E-mail address: vs342@cam.ac.uk (V. Selimi).
The surgical centre’s Electronic Medical Record (EMR) system,
which includes records from 2008, was used to conduct a
retrospective analysis of patients that had presented to the clinic

http://dx.doi.org/10.1016/j.jor.2016.09.002
0972-978X/ß 2016 Published by Elsevier, a division of RELX India, Pvt. Ltd on behalf of Prof. PK Surendran Memorial Education Foundation.
432 V. Selimi et al. / Journal of Orthopaedics 13 (2016) 431–436
with chronic hip dislocations. Because English is not the first
language of many of the surgeons, a variety of search terms were
used to cover potentially misspelled diagnoses for ‘hip dislocation’
when searching for patients.
EMR patient histories were reviewed and only patients
presenting with dislocations >6 weeks old were included in the
study. This interval is greater than that used by Garrett (>72 h) in
another paper considering chronically dislocated hips, however, no
consistent standard exists for defining chronicity.7,8 Additionally,
congenital hip dislocations were excluded.
The records of patients included in the study were then
examined and the following data abstracted: patient demo-
graphics, injury aetiology, the time delay between dislocation
and presentation, preoperative treatment approach (traction vs.
none), operative treatment approach, and follow up notes.
2.2. Data analysis
Statistical analysis consisted of descriptive statistics for
demographic characteristics, aetiology, delay between dislocation
and presentation to clinic and treatment outcomes (patients were
divided into subgroups based on the type of treatment they
received for the last two).
Fisher’s exact test was used to assess whether there was a
difference in the sex ratio of treated patients.
A one-way analysis of variance (ANOVA) was used to detect
whether the delay between dislocation and presentation to the
clinic differed significantly between patients who received
different treatments at the centre; closed reduction, open
reduction, arthrodesis or total hip replacement (THR) were
analysed. Each of these treatments had been used to treat three
or more patients included in the study; this frequency of use
enabled them to be selected for analysis. Post hoc ANOVA analysis
was performed using Tukey’s honest significance test and Bartlett’s
test of homogeneity of variance.
Operation outcomes, based on follow-up notes and radiograph-
ic evidence discovered during chart review in EMR, were used to
compare the success of the varying treatments.
Data abstracted during chart review was insufficient to reliably
stratify according to Epstein criteria, Garrett criteria, or Oxford Hip
Score7,9,10 which the few other papers examining chronic hip
dislocations have used to assess treatment outcomes. Both the
Garrett and Epstein criteria used non-interval, ordinal grades.7 Like
these scoring systems, we decided to use categorical measures to
simplify outcome analysis; operative outcomes were divided into
‘bad’ and ‘good’ grades.
A ‘bad’ outcome was defined by presence of one or more of the
following postoperatively: need for a revision operation, postop-
erative dislocation, a limited range of movement (ROM) significant
enough to affect daily life (work/household activities), positive
Trendelenburg sign or postoperative necrosis of the femur. Pain, a
limited ROM not affecting daily living and long-term use of
crutches were not considered bad outcomes. While these are not
considered good outcomes in more developed countries where
acute dislocations are treated promptly, we accepted that the
chronicity of the presenting complaint prevents the same
postoperative outcomes being achieved in patients in developing
countries. ‘Good’ outcomes were defined by the absence of follow
up complications that made an outcome bad (described above).
The frequency of good and bad outcomes for the different
treatments used was then compared.
Descriptive statistics were also used to analyse pre-operative
treatment; the number of days patients spent in traction (patients
were again divided into groups based on the treatment they went
on to receive) and the weights used at the beginning and end of
traction were examined.
A Welch two-sample t-test was used to determine whether the
delay between dislocation and presentation differed significantly
between patients with and without preoperative traction, both for
all surgeries and for the restricted subgroup of patients treated
with open reduction. Next, Fisher’s exact test was used to
determine differences in the number of good outcomes between
patients with and without traction prior to open reduction.
Statistical significance for all tests was defined at p < 0.05. All
statistical analysis was performed using R version 3.1.1.
3. Results
72 patients presented to the clinic with chronic hip dislocations.
The average age of these patients was 27 and a statistically
significant majority (71%, p = 0.02) were males. The major causes of
these dislocations were falls (36 cases) and motor vehicle accidents
(MVA) (17 cases).
Of the 72 patients that presented, 42 proceeded to have
treatment at the hospital. The average delay from dislocation to
presentation for these patients was 18 months (range 6 weeks to
13 years). Ten of the patients receiving treatment were not
followed up. For the 32 patients that remained, the average time
from treatment (operation) to the last follow-up was 11 months
(range 20 days to 39 months). Five of the 10 patients lost to follow-
up had good postoperative outcomes noted in their records before
discharge.
A variety of operations were used to treat the dislocated hips
presenting to the clinic. Closed reductions were predominantly
used for patients presenting with hips which had been dislocated
for a short period of time (mean = 1.9 months) (Table 1); open
reductions were used to treat hips which had been dislocated for a
mean of 7.5 months longer than those for which closed reductions
were used. Total Hip Replacement (THR) was only attempted as a
first line treatment for hips that had been dislocated for longer
periods (mean = 10 years). The delay before surgeons opted for
THR was statistically significant when compared to open reduc-
tion, closed reduction, and arthrodesis using ANOVA and Tukey’s
range test (p < 0.0001). Bartlett’s test of homogeneity of variance
showed that the subgroup samples were non-normally distributed
(K2 = 48, df = 3, p < 0.0001). When Welch’s t test was used to
compare the delay to treatment between open and closed
reductions, closed reduction was associated with shorter delays
( 0.64 to 14.48, 95% CI, p = 0.03).
Fig. 1 highlights the outcomes of the different operations used
to treat the dislocated hips. The most common operations were
open reductions (n = 24) and closed reductions (n = 7). If only
patients for which there is follow-up data are considered, 63% of all
chronic hip dislocations treated had good outcomes and open
Table 1
Table showing the delay between hip dislocation and presentation to clinic for
patients receiving various forms of treatment. (Delay to presentation data for two of
the seven patients treated with closed reductions could not be found in the medical
records).
Treatment Number Delay between
(operation) of patients dislocation and
presentation (months)
Mean Range
Closed reduction 7 1.9 1.5–2
Open reduction 24 9.4 1.5–72
Arthrodesis 4 10 5–14
THR 3 120 48–156
Hemiarthroplasty 1 11 11
Osteotomy 1 60 60
Arthroplasty 1 11 11
Bone graft 1 3 3
Overall 42 18 1.5–156
 V. Selimi et al. / Journal of Orthopaedics 13 (2016) 431–436 433

Success of the varying treatments used for chronic hip dislocations

12 11

Number of patients
10
8 7
6
6
4 3 3 3 Good Result
22
2 1 1 1 1 1 Bad Result
0 00 00 0 0 00 00
0 No post-op Follow up

Treatment (Operation)

Fig. 1. Bar chart depicting the outcomes of varying treatments for chronic hip dislocations used.

reductions, the most common treatment, had good outcomes after
65% of procedures. Because operations other than open reductions
were performed less often, statistical comparisons of outcomes by
procedure type could not be performed.
Some patients received skeletal traction to manoeuvre the head
of the femur into the acetabulum before operative treatment. On
average, patients who had, had traction received it for 9.9 (range 1–
15) days before operative treatment; on average, a start weight of
11.0 kg (range 1–20 kg) was utilised and increased to 13.7 kg
(range 2–30 kg) just before treatment. Patients receiving traction
preoperatively had hips that had been dislocated for an average of
one month longer (25 patients; delay to presentation average:
19 months, range: 6 weeks–5 years) than those who did not receive
traction (17 patients; delay to presentation average: 18 months,
range: 6 weeks–13 years) when the type of operation was not
considered. This difference was not statistically significant
(p = 0.93). However, when the individual type of operation was
considered e.g. open reduction, use of traction tended to be
associated with hips that had been dislocated for longer periods.
The number of patients in each treatment category and the
time elapsed between dislocation and presentations are pre-
sented in Table 2. This highlights the time elapsed between
dislocation and presentation tended to be higher in the subgroups
treated with traction. The number of patients with good results,
bad results, and no follow-up by treatment subgroup are also
presented in Table 2.
Preoperative traction vs. no traction was compared in the open
reduction group only (this was the only group large enough to
divide into two pre-operative sub groups). Seven of ten (70%) with
traction had good results whilst 4/7 (57%) of those without traction
had good results—a difference of 13% (Fig. 2). Using Fisher’s exact
test, traction in this group was associated with more good
outcomes (OR = 1.69, 0.15–20.06, 95% CI), but this result was
not statistically significant (p = 0.6437). Importantly, preoperative
patient characteristics differed significantly between those with
traction and those without. The traction group had dislocations
that had been present for nearly 12 months longer (15 vs.
3.23 months). Although the sample sizes were small, this
difference approached statistical significance using Welch’s t-test
(p = 0.11). Presumably, surgeons thought the pull of the muscles
would not be strong in dislocations that were more recent, and
surgeons would therefore be able to generate enough force to pull
the head of the femur into the acetabulum during surgery. Of the
4 patients with no traction who had good results, 2 had operations
one day after presenting to the surgical centre and the average time
between presentation and operation was 2.75 days. It is therefore
unlikely that these patients had traction that was not documented
by EMR in such short intervals.

Table 2
Table highlighting the delay between dislocation and presentation for patients with chronically dislocated hips; operations are subdivided to indicate whether or not a group
of patients received pre-operative traction or not. The operative outcomes of each sub group are also noted. (Delay to presentation data for two of the seven patients treated
with closed reductions could not be found in the medical records).

Operation Number Delay between dislocation Number of patients with a given result
of patients and presentation (months)

Mean Range Good Bad No follow up

Closed reduction (no traction) 7 1.9 1.5–2 2 2 3

Closed reduction (traction) – – – – – –
Open reduction (no traction) 12 3.2 2–11.5 4 3 5
Open reduction (traction) 12 15 1.5–7.2 7 3 2
Arthrodesis (no traction) 3 8.7 5–11 – 3 –
Arthrodesis (traction) 1 14 14 1 – –
THR (no traction) 2 156 156 2 – –
THR (traction) 1 48 48 1 – –
Hemiarthroplasty (no traction) – – – – – –
Hemiarthroplasty (traction) 1 11 11 1 – –
Osteotomy (no traction) – – – – – –
Osteotomy (traction) 1 60 60 – 1 –
Arthroplasty (no traction) 1 11 11 1 – –
Arthroplasty (traction) – – – – – –
Bone graft (no traction) – – – – – –
Bone graft (traction) 1 3 3 1 – –
434 V. Selimi et al. / Journal of Orthopaedics 13 (2016) 431–436

The effect of pre-op

perative tracction for thee open
redduction of chronic
c hip ddislocationss
8 7

Number of patients
7
6 5
5 4
4 3 3
3 2
2
1 Traction
0 Tractioon
Good Result
R Bad Resuult N
No follow up
Trreatment Ou
utcome

Fig. 2. Bar chart reflecting the outcomes of chronic hip dislocations treated with open reductions based on whether or not pre-operative traction was utilised.

Fig. 3 exhibits pelvic radiographs of a patient’s chronically
dislocated hip on presentation; post-traction, with movement of
the femoral head into the acetabulum (preoperatively) and a good
outcome, post-open reduction, upon follow up.
4. Discussion
4.1. Treatment options
In the developing world, treatment of dislocated hips is often
delayed. In Cambodia, a marked delay in presentation is frequently
due to the use of Khmer Traditional Medicine (KTM) prior to
seeking western medical advice. A previous study of chronic hip
dislocations in Cambodia found that 82% of 33 patients presented
to a clinic providing KTM prior to seeking Western medical
treatment.11 Other barriers to care include lack of knowledge of
free NGO medical services such as this clinic, the price
transportation to access treatment, and the opportunity cost
associated with time away from employment.
Therefore, this study aimed to help guide the treatment of those
presenting with chronically dislocated hips in developing coun-
tries. By examining the follow-up data of patients presenting with
dislocations >6 weeks old, we were able to identify the outcomes
of varying treatments for chronic hip dislocations performed at the
centre. Among the 32 patients with follow-up data, 63% had good
outcomes. It is, however, difficult to compare the success of these
operations to those considered in other studies because so few
studies have documented surgical outcomes in hips that have
remained unreduced for more than 6 weeks.
Historically, open reduction has been a more common approach
in the developing world and is associated with acceptable
outcomes. A 1999 study based on 12 late unreduced traumatic
posterior hip dislocations in children in hospitals in India and
Malaysia reported 11 excellent outcomes using a standard lateral
open reduction after insufficient reduction with traction alone.3
Other contemporary surgeons have reported similar success with
open reductions.3
Our study showed that open reductions, used most commonly
to treat chronically dislocated hips at the centre, were successful
65% of the time. It is, however, challenging to compare the
efficacy of this treatment to that of other operations for two
reasons: (1) closed reductions were predominantly attempted on
hips which had not been dislocated for as long as open
reductions, and (2) other operations were not used frequently
enough to obtain a large enough sample to make statistical
comparison possible.
Similar to our study, previous scholarship has suffered from
small sample sizes due to the relative rarity of a presenting hip
with significant treatment delay. One study in the United States of
39 traumatic hip dislocations that had remained unreduced for
over 72 h found that THR may be associated with more ‘good’
outcomes (10 of 13 hips) compared to closed or open reduction
(3 of 20) and hips left dislocated (0 of 6).7 In our study, all 3 (100%)
of hips treated by THR had good outcomes, despite these patients
presenting after significant treatment delay (mean = 120 months).
However, due to the low number of patients treated with THR
(n = 3), it was not possible to compare the results of THR to open
reduction.
Prostheses were not very commonly used at the centre; this is
partially due to cost and the technique the centre uses to decide
whether or not one is necessary. Intraoperatively, when the
femoral heads were exposed at operation, they were drilled with a
3.5 mm bit and observed for bleeding. A majority of the heads bled
on drilling (Fig. 4) and were deemed vascularised so fit to be
reduced if possible. If they did not bleed, avascular necrosis was
diagnosed, and the femoral head was replaced with a prosthesis.
Sometimes, the femoral head bled but was soft and indented while
trying to reduce it, producing a ‘‘ping-pong sign’’. In such cases, a
prosthesis was also used. Acetabular replacement was only carried
out if the acetabulum was damaged, but capable of being
reconstructed with a prosthesis; otherwise, if the acetabulum
was severely deformed, hip arthrodesis was performed or a
Girdlestone arthroplasty was done.
Drilling the femoral head was used to identify avascular
necrosis; bleeding obviously indicated that the head had a blood
supply. However, it is perfectly possible that in the majority of
cases, avascular necrosis of the head might have taken place when
the dislocation was experienced; since such a long time had
elapsed after injury in the majority of cases, ‘‘creeping substitu-
tion’’ had revascularised the head.12 Similarly, inadvertent
indentation of the head during reduction indicated osteoporosis,
but whether this was due to ‘‘creeping substitution’’12 or to ‘‘disuse
osteoporosis’’13 was impossible to determine.
Postoperatively, to maintain reductions, spica cast were used
for 6 weeks at the centre.
There were a variety of complications that led to 12 patients
having ‘bad’ outcomes. The two that received closed reductions as
an initial treatment were classed as ‘bad’ as reductions were not
achievable with this initial treatment and, open reductions had to
be used. The 6 ‘bad’ open reductions had a variety of complications;
post-operative dislocation (1 patient), subluxation (1 patient),
impaired ROM (2 patients), substantial pain (1 patient), Trende-
lenberg +ve (1 patient). Two patients went on to have recorded
revision operations; one due to subluxation and the other due to
the surgeons not being able to reduce the hip intra-operatively (no
pre-operative traction had been used). The three arthrodesis that
were ‘bad’ had all failed to fuse. The ‘bad’ osteotomy was
complicated with partial necrosis of the femur.
 V. Selimi et al. / Journal of Orthopaedics 13 (2016) 431–436
Fig. 3. Top: Pelvic radiograph of a chronically dislocated hip at presentation, three
months after the causative fall. Middle: Pelvic radiograph two days after
presentation. Skeletal traction with 10 kg was used. An open reduction was
preformed seven days after this. Bottom: Radiograph preformed on follow up. This
patient had a good outcome.
435
Fig. 4. Drilling of femoral head produces bleeding.
4.2. Pre-operative treatment
Whilst it has been shown that traction before open reduction
seems to improve postoperative outcomes (70% with traction vs.
57% without), our results were not statistically significant
(p = 0.6437) due to the small number of patients in this study.
Furthermore, there is a paucity of follow-up data for a relatively
large number (n = 5, 42%) of patients in the ‘no traction’ treatment
group. If these patients had bad outcomes, it would add more
validity to the use of preoperative traction. However, it is also
possible that lack of follow-up indicated a successful operation,
and that more aggressive surveillance of patients would further
prevent rejection of the null hypothesis. More concerning,
statistically, is the difference in patient characteristics between
patients treated with and without traction. The subgroup with
traction presented with hips that had been dislocated for a longer
mean period (15 vs. 3.23 months, p = 0.11), which may have
predisposed them to worse outcomes due to vascular compromise,
degenerative arthritis, or sciatic nerve injury. Due to these
differences, our results remain equivocal.
4.3. Difficulties with follow-up data
The manner in which follow-up data was recorded in the clinic
EMR was not consistent. For example, in several instances, the
postoperative state of the hip and ROM were not documented. In
such cases, the progress was usually noted as ‘good,’ so it was
assumed that the patient had a good outcome that did not require
further discussion. Omission of potentially relevant outcome data
makes it possible that our results inflate the success of operations.
Furthermore, comparing the success of operations was
complicated by low rates of follow-up and small sample sizes in
treatment subgroups. To power the study and provide greater
validity, a larger sample size, over a greater period of time must be
studied. However, due to the relative rarity of chronically
dislocated hips, it is important to publish surgical outcomes even
when population sizes are insufficiently large to power compara-
tive analysis. Few single clinics in the developing world are likely
treat enough chronically dislocated hips to achieve appropriate
statistical power for comparisons across a range of treatment
strategies.
Future prospective analysis of patients presenting with chronic
hip dislocations may provide a more accurate reflection of a
patient’s journey at the clinic as it would rely less on retrospective
inspection of patient records that do not always contain sufficient
data to make a clear diagnosis or an assessment of outcome quality.
436 V. Selimi et al. / Journal of Orthopaedics 13 (2016) 431–436
Moreover, it is also important to consider that the time point of the
last follow up from operation varied between patients; the patients
are therefore at different time points in recovery, potentially
affecting outcome data. A given follow-up period may therefore be
set in the future to allow for a more accurate comparison of
outcomes.
Another issue was also the loss of patients to follow up; this is
common in free or low-cost surgical clinics in Cambodia and the
developing world. In the present study, 76% (32/42) of patients
receiving surgical operations completed follow-up. Although lost
patients may have introduced selection bias, 76% is an acceptable
rate of follow-up given socioeconomic and geographic constraints
in a low resource setting in Cambodia. Patients often lack the
financial assets required to return for follow-up, which may seem
less important than the surgical operation itself, especially when
complications are absent. Although outcome data may be
increased through aggressive post-discharge surveillance (e.g. by
phone or home visits), such an approach costs time and money and
preoccupies clinic staff. Furthermore, according to some research
in other resource-poor settings, such a strategy would not
significantly increase identification of complications.14
5. Conclusion
The data indicates that open reductions are an appropriate
treatment strategy for chronically dislocated hips and that pre-
operative traction is associated with better outcomes. Unfortu-
nately, none of the results are statistically significant. Whilst
chronically dislocated hips are rare worldwide, they are a common
problem in the developing world and no single surgical centre is
likely to have a large enough patient population to power a
comparative study. Therefore, it is vital to present this work so that
it, alongside that of others, can help guide the future treatment of a
condition which is debilitating for so many in the developing
world.
Conflicts of interest
The authors have none to declare.
References
1. Dwyer AJ, John B, Singh SA, Mam MK. Complications after posterior dislocation of
the hip. Int Orthop. 2006;30(4):224–227.
2. Foulk DM, Mullis BH. Hip dislocation: evaluation and management. J Am Acad
Orthop Surg. 2010;18(4):199–209.
3. Kumar S, Jain AK. Open reduction of late unreduced traumatic posterior hip
dislocation in 12 children. Acta Orthop Scand. 1999;70(6):599–602.
4. Kutty S, Thornes B, Curtin WA, Gilmore MF. Traumatic posterior dislocation of hip
in children. Pediatr Emerg Care. 2001;17(1):32–35.
5. Yang RS, Tsuang YH, Hang YS, Liu TK. Traumatic dislocation of the hip. Clin Orthop
Relat Res. 1991;(265):218–227.
6. Sahin V, Karakaş ES, Aksu S, Atlihan D, Turk CY, Halici M. Traumatic dislocation and
fracture-dislocation of the hip: a long-term follow-up study. J Trauma. 2003;54(3):
520–529.
7. Garrett JC, Epstein HC, Harris WH, Harvey Jr JP, Nickel VL. Treatment of unreduced
traumatic posterior dislocations of the hip. J Bone Joint Surg Am. 1979;61(1):2–6.
8. Pai VS, Kumar B. Management of unreduced traumatic posterior dislocation of the
hip: heavy traction and abduction method. Injury. 1990;21(4):225–227.
9. Thompson VP, Epstein HC. Traumatic dislocation of the hip; a survey of two
hundred and four cases covering a period of twenty-one years. J Bone Joint Surg
Am. 1951;33(3):746–792.
10. Dawson J, Fitzpatrick R, Carr A, Murray D. Questionnaire on the perceptions of
patients about total hip replacement. J Bone Joint Surg Br. 1996;78(2):185–190.
11. Butler D, Archer C, Gollogly J, Ngiep OC. Chronic traumatic hip dislocation: the
Cambodian experience. Asian Biomed (Res Rev News). 2011;5(5):705–712.
12. Plenk Jr H, Hofmann S, Breitenseher M, Urban M. Pathomorphological aspects and
repair mechanisms of femur head necrosis. Orthopade. 2000;29(5):389–402.
13. Takata S, Yasui N. Disuse osteoporosis. J Med Invest. 2001;48(3–4):147–156.
14. Young S, Banza LN, Geir H, et al. Complications after intramedullary nailing of
femoral fractures in a low-income country. Acta Orthop. 2013;84(5):460–467.